March Journal Round-Up

Welcome to the March journal round-up!

Trauma – Blunt cerebrovascular injury presents a significant clinical and radiological problem, as it can be very difficult to detect but screening all patients risks overutilization of limited resources and potential overdiagnosis. Two articles this month tackle this issue – a concise review by Nagpal et al. in AJNR compares the available diagnostic criteria and grading scales, whilst Rutman et al. in Radiographics provide a more comprehensive pictorial review with a focus on explaining the underlying pathophysiology.

Another common pathology associated with blunt trauma, thoracolumbar spine injury, is the subject of a review by Bonfante et al. in Neurographics, who discuss the pathology and biomechanics of injury to this region, compare the available classification systems for the injuries and discuss the clinical utility of these systems. This is a useful reference for anyone reporting trauma studies.

Vascular Last month we included the ASNR’s guidance on vessel wall imaging. This month Pinho et al. in Neurographics give us a practical guide to vessel wall imaging, covering technical guidance on optimising imaging protocols and normal and abnormal findings. Potential expanded roles for vessel wall imaging are covered in two further articles this month – Dlamini et al. examine the application in paediatric stroke, and Lehman et al. in JNS review its use in aneurysm imaging (table 1 is an excellent reference guide to the findings in different types of aneurysm).

With the increasing use of T2* and susceptibility weighted imaging as well as higher field strengths, microhaemorrhages are being detected with greater frequency and it can be difficult to determine their significance. Haller et al. in Radiology provide a clear and relevant review that covers their detection, radiological-pathological correlation and their significance to multiple disease processes, as well as normal ageing.

Intervention – Two studies this month provided further evidence for the potential to extend the role of mechanical thrombectomy beyond large vessel occlusion within 6 hours of symptom onset. Following encouraging evidence from prospective trials, a retrospective study by Bucke et al. looked at the outcomes of patients with wake up strokes and strokes of uncertain daytime onset time in comparison to their ‘control’ cohort of within-time mechanical thrombectomy, and showed equivalence of the outcomes of the wake-up stroke cohort with controls and also a benefit related to the use of advanced imaging (i.e. MRI and CT perfusion). Haussen et al. used two prospective registries to compare mechanical thrombectomy with medical treatment alone in patients with mild symptoms (NIHSS </=5), and demonstrated a benefit in discharge NIHSS for mechanical thrombectomy.

Inflammatory – A review in Nature Reviews Neurology by Geraldes et al. should be required reading for neuroradiology trainees – the MAGNIMS study group reconvened to update their ‘red flags’, radiological signs that should alert the radiologist against a diagnosis of multiple sclerosis in the presence of white matter lesions. Given the prevalence of nonspecific white matter lesions in neuroradiology practice, this remains a frequent problem and their mnemonic ‘MIMICS’ is valuable to remember pointers towards other causes.

One aspect the authors of the above review touch upon is the central vein sign (veins running within the centre of white matter lesions), a presumed biomarker to distinguish MS from other causes of white matter lesions, which has been around for a while but has gained traction more recently with a publication by NAIMS on its evolution and use in 2016. An editorial in Neurology this week by Miller suggests this sign is ready for clinical use, expanding on an article by Cortese et al. demonstrating the sign’s value in distinguishing between MS and NMO spectrum disorders.

Paediatric – An article in AJR by Orru et al. provides a simple and effective approach to the assessment of the child with macrocephaly, with suggested imaging protocols and a pictorial review of common and less common causes.

Miscellaneous – Finally, a fascinating article by Reicher et al. in BJR examines the working practice of UK neuroradiologists and asks what we can learn from the aviation industry, specifically air traffic controllers who perform a qualitatively similar job, and cognitive science about how to improve it. The discrepancy between working practices as described by surveys conducted of the two professions and its potential impact on performance makes for thought-provoking reading!

That’s all for this month. As ever, let us know if there’s anything important we’ve missed, and have a good month!

February Journal Round-Up

Welcome to the February journal round-up!

Vascular – It’s a bit stroke-heavy this month, so a good place to start is the new American Heart Association stroke guidelines, published in Stroke. Although you may not want to read all 345 pages, the short sections on imaging and thrombectomy are a useful summary of the level of evidence for various factors that will affect us as radiologists, and are worth a read.

As a useful adjunct to this for neurointerventionalists, the Society of Neurointerventional Surgeons have also published updated guidance on mechanical thrombectomy, focusing on the evidence base for specific technical aspects of the procedure, in JNIS.

And for a more detailed discussion of the specific imaging modalities and their strengths and weaknesses in imaging evaluation of stroke, Smith and Rowland Hill have also provided a comprehensive review in the BJR.

Evaluation of carotid disease is clearly a crucial part of stroke imaging, and the relatively new technique of vessel wall imaging is an exciting prospect for this application. The ASNR have published a white paper with their recommendations for the use of vessel wall imaging, which provides an excellent context for where it can be most clinically useful.

Dural arteriovenous fistulae are notoriously difficult to diagnose, and in AJNR this month Copelan et al. describe a case series for a particular characteristic appearance of medullary oedema and enhancement in Cognard type V fistulae, noting the importance of recognising these features to avoid a long work-up for alternative pathologies.

Neoplastic – After the discussion of machine learning techniques in neuroradiology last month, the discussion in AJNR now focuses down on to its use in brain tumours in the new field of ‘radiomics’, noting the particular utility in neuro-oncology because of the potential to align imaging and genetic findings.

Inflammatory – Antibody-mediated encephalitides are increasingly understood to be much more common than we thought – indeed the most common, anti-NMDAR encephalitis, is more common than herpes encephalitis in young people. Yet this can seem like a bewildering array of random letters to the uninitiated! An excellent review in NEJM gives clinical context and highlights useful imaging findings to provide an introduction to these important pathologies.

Erdheim-Chester disease is a rare non-Langerhans cell histiocytosis, and Parks et al. in Neurology Clinical Practice use their relatively large cohort of 53 patients to examine the neuroradiological features of this disease.

Spine – The journal Neurosurgery have a useful (and open access) neuroradiology review series, and I have highlighted two articles from the series in this month’s blog. The first, by Chokshi et al., examines spinal neoplasms (both vertebral and cord) and also provides a very useful post-treatment section, particularly the imaging appearances of radiation-related complications.

Miscellaneous – Epilepsy imaging is an extremely challenging area for neuroradiology trainees, and there is a helpful review in Current Opinion in Neurology by Ruber et al. which focuses on accurate protocolling and the roles of advanced imaging for presurgical planning, as well as looking to potential future applications.

The second Neurosurgery neuroradiology review article, by Hudgins & Baugnon, concerns the skull base and provides an excellent overview and pictorial review of the anatomy and pathology of this complex region.

That’s all for this month. Hope you found it helpful, and do let us know if we’ve missed anything!

January Journal Round-Up

Welcome to the January journal round-up! Before we begin, we are pleased to announce the BSNR Trainee Study Days will be held in Newcastle on May 10-11th, with a focus on paediatric and spinal imaging and a mixture of lectures and workshops, modeled on the successful pre-annual meeting trainee days. Please email bsnr.traineeday@gmail.com to register your interest or for more information.

Vascular/Intervention – There is more support for extended (>6 hours) thrombectomy for proximal anterior circulation occlusions with the publication by Albers et al. in NEJM of results from the DEFUSE 3 trial. Using CT or MR perfusion and an automated imaging postprocessing system to select patients, they showed in an RCT that intervention following medical therapy up to 16 hours still conferred benefit.

Jansen et al. in Radiology went looking for other imaging correlates of response to intra-arterial therapy. They retrospectively used MR CLEAN trial data to examine whether a score based on the degree of cortical vein opacification (‘COVES’) on CT angiography could predict outcome, showing a higher mortality and no shift towards better functional outcome following intra-arterial treatment in those with a COVES (calculated looking at the superficial middle cerebral vein, vein of Labbe and the sphenoparietal sinus) of more than 0.

Neoplastic – In Practical Neurology, Larsen et al. give a timely overview of the role of imaging in the diagnosis, treatment planning and monitoring of low-grade glioma, in view of the trend towards more aggressive treatment and the changes in the 2016 WHO classification.

Leaning more towards treatment, Patibandla et al. have summarised the applications of stereotactic radiosurgery to help the neuroradiologist in the neuro-oncology MDT, with a pragmatic approach to the imaging aspects of common usages.

Inflammatory – It was all about multiple sclerosis (MS) this month, with the updated McDonald criteria published in the Lancet Neurology – key changes including the demonstration of CSF oligoclonal bands, the admissibility of symptomatic lesions in determination of dissemination in space or time, and the inclusion of cortical lesions with juxtacortical lesions. And just in the nick of time, as in the same journal a retrospective study by Filippi et al demonstrated equivalence of the 2010 McDonald criteria with the 2016 MAGNIMS criteria in predicting progression from clinically isolated syndrome, but highlighted possible areas for future development (at least one of which, the symptomatic lesions, has been incorporated into the new McDonald guidelines).

An appropriately timed overview of the current state of knowledge in MS is provided by Reich et al. in NEJM, and although the imaging aspect is limited this is a valuable and clear summary of our understanding of the complex pathophysiology of this still poorly understood disease.

A major set of differential diagnoses of MS are NMO (neuromyelitis optica)-spectrum disorders, and fortunately Garbugio Dutra et al. have published an excellent review of the history, diagnostic criteria, imaging features and differentials for these diseases.

Away from demyelination, IgG4-related disease is an increasingly diagnosed systemic disorder and its central and peripheral nervous system manifestations are outlined in a useful review by AbdelRazek et al. As it can mimic a number of other conditions, the detailed knowledge of the clinical context and systemic manifestations provided is crucial and the imaging features are also helpfully outlined.

Degenerative – Two interesting articles this month examined the diagnostic criteria for cerebral amyloid angiopathy (CAA), increasingly recognised and important in older populations (see the August round-up for more clinical context). In Stroke, Greenberg and Charidimou examine the evolution and validation of the most commonly used diagnostic criteria, the Boston criteria, and look at future directions for its development.

Conversely, Rodrigues et al. in Lancet Neurology set out to develop criteria to determine CAA as the cause for intracranial lobar haemorrhage on CT (the Edinburgh CT criteria), and found that two imaging findings, concurrent subarachnoid haemorrhage and ‘finger-like projections’ from parenchymal haemorrhage, in combination with APOE4 allele possession, had high specificity for CAA. The accompanying comment by Werring points out the need to compare these two sets of criteria and the potential strengths of both.

Paediatric – Neuroimaging is critical in the evaluation of paediatric traumatic brain injury, and a review by Mendoza et al. in Neurographics provides a useful summary of the spectrum of findings in accidental TBI, particularly paediatric-specific patterns of injury, and the emerging uses of advanced imaging in this context. In Emergency Radiology, Tang et al. examine the emergency vascular conditions seen in paediatric populations, with a focus on the importance of recognising stroke mimics.

Miscellaneous – Treatment effects are often a difficult or forgotten area and so a comprehensive review of treatment-related CNS abnormalities by Lincoln et al. in BJR is very welcome, covering the spectrum of side effects including PRES, IRIS, radiation and newer biologic agents and their specific complications.

And finally, we are constantly threatened with obliteration as radiologists by artificial intelligence and specifically deep learning. A review by Zaharchuk et al. in AJNR gives an in-depth explanation of the process by which deep learning can have useful applications in neuroradiology – but also provides hope that this will help rather than replace us!

That’s all for now, see you next month!

2017 Year in Review

Happy new year!

No full journal round-up this month, but I thought I would just do a brief summary of the year and highlight the most popular articles featured on the blog this year. There have been visitors from 40 countries over the last six months since its inception, and thank you to everyone who has fed back and particularly those who have contributed.

The top 5 articles (by click-through) from last year were:

Adams B et al. “Kinks and Clefts”: A Review of Congenital Brain Stem Abnormalities. Neurographics

An excellent overview of a complex topic – and gratifying that the most popular article this year was written by a UK trainee!

Johnson DR et al. 2016 Updates to the WHO Brain Tumour Classification System: What the Radiologist Needs to Know. Radiographics

The updated WHO classification, with particular emphasis on genetic factors, have dominated much of the neuro-oncology discussion this year so no surprises that this useful summary in Radiographics was a popular read.

Nguyen VD et al. Demystifying Orbital Emergencies. Radiographics

A comprehensive review of this often overlooked area, this is an excellent reference for orbital pathology.

Arnoux A et al. Imaging characteristics of venous parenchymal abnormalities. Stroke

This was a useful cohort review, which outlined the anatomical areas of abnormality related to the most common sites of venous occlusion.

Jansen O et al. Standards of Practice for Interventional Neuroradiology. Neuroradiology

With much of the year dominated by discussion of the utility of mechanical thrombectomy and how it will be implemented, this was a timely consensus statement for safe and effective use of interventional neuroradiology procedures.

Next year, we are looking forward to the BSNR Trainee Study Days on May 10-11th in Newcastle, and the BSNR Annual Meeting (and preceding study day) which is joint with the Irish Society of Neuroradiology and will be held in Dublin on 11-13th October 2018.

Hope you have an excellent 2018! See you next month.

November journal round-up

Welcome to the November round-up! There is a real wealth of interesting articles this month – these are my pick but do let us know what you have found useful.

Intervention – The big news this month was the reporting of the DAWN trial in the New England Journal of Medicine. The results had been eagerly awaited as it was strongly suspected that the timeframe for effectiveness of mechanical thrombectomy is longer than the traditional 6 hours, and sure enough there was significantly increased functional independence and reduced disability in the group that had a thrombectomy at 6 to 24 hours compared to the control group, with no significant difference in mortality or symptomatic haemorrhage. Importantly, the inclusion criteria specified demonstration of a mismatch between clinical severity and infarct volume as measured using CT perfusion or MRI DWI. This will obviously have major implications for organisation of stroke imaging and thrombectomy services.

Supportive evidence was also provided this month in the form of a subgroup analysis of the ESCAPE trial published in AJNR, which demonstrated a benefit for treatment within an extended time window (5.5-12 hours).

Vascular – Predicting progression of infarct is an important aspect of treatment and an article by Bouluois et al. in JAMA Neurol addresses a crucial issue, that if patients are transferred their infarct may progress beyond potential for treatment during the transfer. They assessed imaging factors associated with this progression in transferred patients, and found that collateral supply and clinical severity were key factors in determinants of infarct progression, suggesting a role for collateral assessment (they used a modified version of the Maas rating scale) in baseline stroke imaging.

Arnoux et al. in Stroke examined the imaging characteristics of the brain parenchyma related to cerebral venous thrombosis, looking at their own case series and identifying useful imaging features. They found that haemorrhagic ischaemia was the most common associated feature (followed by intracranial haemorrhage and non-haemorrhagic ischaemia), and determined six foci where parenchymal abnormalities occurred, with the inferior parietal lobule being the most common, and correlation between vessel and anatomical area.

Emergency – As everyone at RSNA this year will be acutely aware, artificial intelligence and deep learning are here to stay and an interesting article in Radiology by Prevedello et al. provides one example of how it may be used. They developed a system for identifying major abnormalities and showed good sensitivity and specificity for haemorrhage, mass effect and hydrocephalus (90% and 85% respectively) and reduced sensitivity but increased specificity for acute infarct (62% and 96%). This was for thick-section non contrast CT head, and the authors suggest this could help speed up workflow by highlighting critical cases to the radiologist.

Also in Radiology, Rodriguez-Luna et al. assessed the utility of the ‘spot sign’ to predict expansion of intracranial haemorrhage, and found that the use of multiphase CT angiography allowed greater stratification of risk with respect to the spot sign, with a more arterial ‘spot’ more predictive of haemorrhagic expansion.

Tumour – There is plenty to choose from this month, starting with a focused review on the aspects of the 2016 WHO classification of brain tumours relevant to radiologists in Radiographics. This is complemented by a more detailed review in Neurographics on the molecular subgroups of medulloblastoma described in the 2016 classification, covering specific imaging characteristics.

Also in Neurographics, Shin et al. provide an excellent overview of CNS lymphoma and its manifold presentations in immunocompetent and immunocompromised patients, with reference to advanced imaging techniques.

Finally, the humble vestibular schwannoma gets a whole review to itself in AJNR, covering diagnosis and imaging pathway but focusing on treatment options and follow-up, and is neatly accompanied by an article in JNS by Wu et al. specifically addressing post-Gamma Knife imaging appearances and predictors of treatment outcome.

Degenerative – The advent of susceptibility weighted imaging has led to an increase in the diagnosis of superficial siderosis, and an interesting study by Pichler et al. in Stroke investigated the prevalence in an elderly population. They found the incidence increased with age (0.21% at 50-69, 1.49% >69) and correlated with higher Apolipoprotein E e2 genotype and a higher likelihood of a positive amyloid PET, implicating cerebral amyloid angiopathy as the most common mechanism, and they therefore suggest follow-up imaging to assess risk of further haemorrhage.

The many different causes of dementia are covered in a comprehensive review by Desai et al. in Neurographics – the detailed table covering the imaging and clinical features of the different aetiologies is a particularly handy quick reference guide.

Paediatrics Adams et al. present an in-depth review of congenital brain stem abnormalities, and manage to make a complex topic admirably clear and practical, using the embryological and molecular underpinnings of the brain stem to classify the imaging phenotypes.

In Pediatric Radiology, Linscott et al. examine venous disease in children, covering the pathophysiology and the imaging features of acute and chronic venous injury.

Miscellaneous – An MDT can be a great opportunity to learn and share knowledge with fellow clinicians, or can be an opportunity for humiliation for an unsuspecting trainee. A survey by the JRF published in the BJR looks at the trainee experience of MDTs and subsequently provides a guide to approaching MDTs based on their findings. This can often be insufficiently covered in training and the article provides a good opportunity to think about training needs in this context, and is well worth a read.

That’s all for now, see you next month!

 

 

 

October Journal Round-Up

Welcome to the October journal round-up!

Vascular Mokin et al. tackle the issue of ASPECTS subjectivity in an interesting article in Stroke this month, using Hounsfield unit measurements (as a ratio and subtraction with the unaffected side) to provide a more objective measure and pave the way for automated image interpretation. This would hopefully standardise and speed up management decisions in thrombectomy, but requires validating in more extensive datasets.

Also considering automated assessments, Hanning et al. developed an automated segmentation and analysis of white matter lesion density on CT and showed a reasonable correlation with subsequent MRI white matter lesion load, which they felt may also lead to more rapid treatment decisions in acute stroke.

Baradaran et al. in AJNR performed a systematic review looking at high-risk features of carotid plaque on CTA, finding that the presence of soft plaque, plaque ulceration and increased carotid wall thickness correlated with ipsilateral ischaemia, whilst plaque calcification had a negative relationship with ischaemia.

Intervention – Two important studies in JNIS this month are again focused on thrombectomy. Frei et al. share their experience of using a standardized thrombectomy protocol (from pre-hospital to IR suite), and show a significant reduction in door to recanalization time. Alondo de Lecinana et al. describe the results of a prospective observational study showing that mechanical thrombectomy is safe and should be performed in patients with contraindication to intravenous thrombolysis.

Tumour – In Neurographics this month, there is a focus on glioma with reference to the 2016 WHO tumour classification (available here). A two-part review by Arevalo et al. in the first part gives an overview of basic tumour genetics covering significant mutations and the updated classification of gliomas, and in the second focuses on imaging features associated with the IDH mutant and wild type (see also the July blog and the review by Smits et al.).

Also with reference to the updated classification, a case series by Nunes et al. in AJNR examines the recently reported entity of a multinodular and vacuolating neuronal tumour, which is a ‘don’t touch’ lesion, and its imaging characteristics.

Inflammatory – Double inversion recovery remains a potentially powerful tool in MS imaging, and Eichinger and colleagues in AJNR have investigated a pre and post contrast and subtraction protocol to compare it to T1 weighted imaging. They demonstrate that DIR is more sensitive in detecting enhancing lesions, and suggest it as an alternative to T1 imaging.

Degenerative – Structural MRI can be of limited use in the setting of motor neuron disease, although volumetric MRI can demonstrate areas of parenchymal loss. Senda and colleagues looked at whether imaging characteristics (volume and DTI) could predict progression in motor neuron disease. They showed that atrophy and particularly grey matter loss, and a decrease in fractional anisotropy, in specific areas beyond just the corticospinal tract correlated with an increased rate of clinical disease progression.

Spine Cardenas et al. provide a useful and comprehensive pictorial review of pathologies of the conus medullaris and cauda equine in Neurographics, covering the spectrum of congenital, infectious/inflammatory, vascular, traumatic and neoplastic aetiologies.

Paediatrics – There is a focus on the rare Menkes disease in AJNR, with a two part review focusing on the vascular/white matter and grey matter changes in this progressive disorder. The authors compare their own case series with the literature for every imaging finding, which makes for a definitive review of this disorder although may be mainly relevant to specialist centres.

More common in everyday practice is the pineal cyst, and Jussila et al. followed up their cohort of pineal cysts in children and showed that the majority do not change, and suggest only re-imaging in the context of unusual radiological features or clinical symptoms.

Although we hope that it will not become necessary in the UK, there is a focused pictorial review in Radiographics this month demonstrating the pre- and postnatal imaging features of Zika virus in the brain covering sonographic and MR findings, and important differential diagnoses.

Miscellaneous – The debate about the use of gadolinium based contrast agents continues, and it is important as radiologists to be informed as to the mechanisms of action being uncovered. A useful review in BJR by the group that initially reported gadolinium deposition in the brain goes through our current knowledge of the mechanisms of gadolinium deposition, and in particular the role of the relatively newly-investigated glymphatic system.

And finally, just in case you wanted another differential for those nonspecific white matter lesions, in Neurology this month Alperin et al. discuss the findings of increased periventricular white matter lesions in returning astronauts. They do not say how often this history was mentioned in the clinical details.

That’s all for now – let us know what you’ve found useful this month!

September Journal Round-Up

Welcome to the September journal round-up (with apologies for the delay). Thank you for the responses to the blogs so far, and please do get in touch with any more ideas for what you would like to see or what you would like to write! Here’s what we’ve been reading this month…

Emergency – Chilvers et al. in Clinical Radiology this month assessed their cohort of trauma cervical spine CT in order to determine the predictors on CT of ligamentous injury on MRI, as well as assessing a normal range of commonly used measurements in this context. They found that in the absence of fractures, the basion-dens interval (>10mm) and widened C0-C1 (>3mm) and C1-C2 (>6mm) facet joints were predictors of significant ligamentous injury at the craniocervical junction, and >50% subluxation of a facet joint and an obscured paraspinal fat pad were predictors in the subaxial spine.

Vascular – The appropriate initial imaging in acute stroke to allow for decisions regarding thrombectomy remains a controversial topic, and in JNIS Ryu et al. have performed a systematic review to assess the utility of perfusion imaging, finding that there is an associated increased probability of a favourable outcome particularly as it may allow inclusion of patients who would otherwise not be considered eligible.

As the treatment of stroke evolves, accurate assessment of CT imaging is paramount. Cora et al. have demonstrated the utility of a validated case archive for training general radiology trainees in the interpretation of CT angiography, showing a reduction in the major discrepancy rate and providing a framework for the case archive which can hopefully be a useful model to extend to other learner groups and topics.

Away from stroke imaging, Silvis et al. provide an excellent clinical overview of venous sinus thrombosis which contains useful context for the radiologist.

Intervention – An important study in Stroke by Achit et al. uses data from the THRACE RCT to demonstrate the cost-effectiveness of mechanical thrombectomy (in combination with intravenous thrombolysis) as opposed to intravenous thrombolysis alone.

In AJNR, Barreras et al. look into a case series of false-negative spinal angiograms, when vascular malformations have subsequently been diagnosed, and highlight important operator factors which led to the misdiagnosis, providing a checklist to avoid similar mistakes in future.

Inflammatory– Multiple sclerosis is on the agenda in AJNR this month, neatly timed ahead of the soon-to-be-unveiled latest update to the McDonald criteria. Two open access articles by McNamara et al. cover the spectrum of multiple sclerosis neuroimaging: the first covers the numerous specific agents used in treatment and the role of MRI, and the second covers pharmacovigilance/safety monitoring and MRI surveillance protocols in more detail.

Infection – Two review articles in Nature Reviews Neurology and Practical Neurology provide an overview of tuberculous meningitis. Wilkinson et al. cover the pathogenesis, clinical features, diagnostic paradigms and management in great detail whilst Shah et al. draw on their experience of patients in East London to provide specific learning points based on five case studies. Taken together they provide useful education on a sadly increasingly common problem.

Degenerative – Normal pressure hydrocephalus can be a difficult diagnosis for the radiologist to make, and Miskin et al. aimed to determine the utility of two techniques, the callosal angle and Evans index. They found that these may act as a useful screening technique to lead to dedicated volumetric imaging.

Paediatric – The risks associated with sedation in children undergoing MRI are not negligible and in Pediatric Radiology, Barkovich et al. examine ways in which the need can be minimise. Protocol rationalisation, motion and noise correction and maximizing the child’s comfort are some possible solutions outlined in this pragmatic article.

Spine Weidauer et al. provide a comprehensive review of imaging of myelopathies, with some excellent diagrams outlining the lesion distribution within the cord for specific aetiologies, and provide a framework for the approach to these tricky clinical scenarios.

That’s all for now, do let us know what you have found helpful this month!

UKNG Annual Meeting Highlights

Dr Juveria Siddiqui attended the UK Neurointerventional Group annual meeting this summer and has kindly recorded some of her highlights from the meeting for us below:

The UK Neurointerventional Group (UKNG) Summer meeting was hosted in Bristol from 9-10th June 2017. It was well-attended by consultant and registrar INRs countrywide, as well as industry representatives. The main focus of the meeting was understandably stroke intervention, with talks covering various aspects of this topic on both days.

The meeting kicked off with a talk on setting up a 24/7 stroke service by UK experts in the field: Dr Andy Clifton (St George’s, London), Professor Phil White (Newcastle), Dr Peter Flynn (Belfast) and Dr Robert Lenthall (Nottingham). Professor White has been closely involved with NHS England’s commissioning of thrombectomy in stroke (announced earlier this year), and discussed American data on mortality citing that smaller units are associated with poorer stroke outcomes.

This suggests that, given the wide range of patient numbers presenting to individual HASUs per year, not every HASU should necessarily provide a stroke thrombectomy service, in order to maintain numbers and encourage skills preservation in units that are service providers. HASUs will likely be expected to demonstrate the numbers performed and their adherence to guidelines in order to continue performing thrombectomy. Following the DAWN trial, which assessed functional outcomes following thrombectomy 6-24 hours following ictus (including wakeup strokes) and terminated early due to high efficacy, the number of stroke patients eligible for thrombectomy is likely to increase.

Following this, talks from Dr Andy Clifton on his experience of implementing a 24/7 stroke thrombectomy service at St George’s Hospital demonstrated that this process required meticulous planning and also discussed the possible hurdles that one may experience. The unit is busy, accepting many patients beyond St George’s catchment area. Dr Clifton discussed the work pattern of the INRs in this unit, based on a 1 in 5-6 rota.

Dr Sanjeev Nayak from Royal Stoke University Hospital followed this with his experience, primarily of stentriever in thrombectomy. His experience of a current 1 in 2 rota covering all neuro-intervention highlighted the need for service expansion and recruitment for the longevity of an INR-led thrombectomy service.

My presentation covered data from the Royal London Hospital’s HASU; a yearlong audit at our unit emphasised that robust initial imaging (CT and CTA) must be a pre-requisite in the quick diagnosis of those eligible for thrombectomy.

Dr Adam Rennie from Great Ormond Street Hospital presented the new RCPCH/Stroke associated Paediatric Stroke guidelines. These guidelines aim to increase awareness of stroke in babies and children, and recommend early unenhanced CT and CTA (neck and intracranial) in any child who is FAST positive but also children with unexplained focal neurological deficit or decreased conscious level. MRI should also be performed if it can be carried out in a timely manner.

The guest speaker, Professor Matthew Gounis, a bioengineering researcher at the University of Massachusetts, USA, provided an intriguing insight into the in-depth laboratory models assessing different clot types and the best modes of retrieval. Use of a balloon guide catheter was associated with improved revascularisation outcomes. There are certain clot types that are easily retrieved, and some that are irretrievable regardless of technique.

There were also a number of excellent talks unrelated to stroke; Dr Wilhelm Kuker’s experience in the pearls and pitfalls of carotid stenting, Dr Andy Clifton’s approach to intracranial vascular lesions in connective tissue disorders and Mr Mario Teo’s neurosurgical management of Moyamoya by vascular anastomosis, following his fellowship at Stanford.

Overall, the meeting was well-organised, interesting and varied, and as well as learning, gave me the opportunity to meet friendly and approachable INRs from all over the UK. There were also useful simulator sessions available. I would recommend the meeting to any budding neuro-interventionalist.

http://ukng.org.uk

Look out for highlights from the BSNR Annual Meeting in the next couple of weeks, and apologies for the delay in the September journal round-up which will be available next week.

Fellowship Experience – Perth, Australia

Dr Lucy Childs is a UK radiology trainee who has been out in Perth, Australia doing her neuroradiology fellowship. She has very kindly shared her experiences and advice on the fellowship with us below:

NIISWA is the Neurological Imaging and Intervention Service of Western Australia.

There is a link here to information about the fellowship: http://niiswa.com/index.php/fellowships.html

There are 3 diagnostic fellows and 1 neuro intervention fellow each year. The fellowship is typically one year long, but can be extended to 2 years, particularly for the interventional fellows.

It’s a tertiary Neuroimaging specialist centre with advanced neuroimaging techniques including CT and MR perfusion, spectroscopy, functional MR imaging etc. NIISWA runs a 24 hour mechanical thrombectomy service for acute strokes, as well as the usual gamut of neurointervention (aneurysms/ AVM management/ stents etc.)

As a fellow you work across two hospital sites: Sir Charles Gairdner Hospital (SCGH) and the Royal Perth Hospital (RPH). These are both public hospitals (like NHS). SCGH is the regional neuro-oncology centre with a large neurosurgical department. The state trauma unit is sited at RPH.

There are two MRI scanners at SCGH one 1.5 and one 3T, (same at RPH). The MRI scanners work almost exclusively performing neuroimaging. The MRI and CT radiographers are excellent, very experienced and tailor scans to the specific clinical requirements, working closely with the neuroradiology team. The MRI scanners work from 0800-1700 for inpatient scanning and 0615-2200 for outpatient scanning with additional out-of-hours oncall service.

The job is busy, there is a large exposure to pathology with a high volume of abnormal scans. Very few ‘normal’ scans are performed by NIISWA. At SCGH CT imaging is reported by general radiologists with referral to NIISWA only when specialist input is required. At this site imaging is predominantly MRI based. All modalities are reported by NIISWA at RPH.

As a diagnostic fellow you are expected to perform fluoroscopically guided lumbar punctures, fluoroscopic and CT guided facet joint injections, fluoroscopically-guided nerve root sleeve injections, fluoroscopically-guided epidural injections and spinal markings prior to surgery. If you are not interested in or not comfortable with performing procedures most days of the week (usually at least 1-2/day) then this fellowship might not be the one for you, as this is entirely expected.

There is the opportunity to do head and neck reporting. H&N reporting is nearly all cross-sectional, with almost no ultrasound imaging as this is performed by sonographers at NIISWA, although you are still part of the FNA service.

As a fellow you actively participate in journal club meetings, CME lectures and MDT presentations. Teaching is generally case based and there is excellent senior consultant supervision at all times.

The pay is excellent. Typically equates to £125,000/ year ($200,000 AUD) when on call payments are included (these are variable). The on call is 1 week in every 4 and you are essentially on call from home 5pm-8am and working your normal hours the rest of the week. Annual leave is unfortunately very low in your first year at only 20 days/year. There are no zero days before or after on calls either.

Western Australia is an enormous geographical area with its own unique challenges. It’s not uncommon for ‘flying doctors’ to bring patients from many hundreds of kilometres away from small remote Australian communities. In combination with socio-economic problems, this leads to cases more often seen in developing countries – indeed it is the only place where I have encountered cases of leprosy.

Overall, this is a very educational fellowship with an excellent supportive neuroimaging team. The downsides would include the lack of time off (to explore the area). Perth also feels like a very ‘new’ city which is currently short on culture and multiculturalism, but is making progressive attempts to improve this. There are also incredible beaches which do go some way in offsetting the lack of art establishments!

Our thanks to Lucy for sharing such detailed information about the fellowship – if you are currently undertaking a neuroradiology fellowship in the UK or abroad, please do get in touch and tell us what you think about it!

August Journal Round-Up

It’s that time of the month again – welcome to the August journal round-up!

Emergency – The longstanding issue of blunt cerebrovascular injury following craniocervical injury was again on the agenda this month; Cook et al. came to the conclusion that for these purposes children may well be little adults, as the modified Denver criteria have a high sensitivity for these injuries. However, the issues of radiation dose and what treatment is appropriate have not yet been settled. To further complicate matters, Grandhi et al. in JNS found that CTA has a high false positive rate for BCVI (in adults), particularly for Biffl grade 1 injuries, and suggest that these should be confirmed with DSA which brings its own problems.

Away from these thorny issues, Rozell et al. present a case based approach to infectious and inflammatory conditions presenting to the emergency department in Emergency Radiology, which may be a particularly useful summary to registrars starting their neuro blocks.

Vascular/Intervention – Optimising endovascular therapy for stroke and the pre-procedural imaging remains a dominant theme of this month’s journal articles. A retrospective analysis of MR CLEAN trial data published in Radiology by Jansen et al. demonstrated that the opacification of cerebral veins (using a scoring system based on three areas) predicted the response to intra-arterial therapy, although this relied on satisfactory venous opacification on a CTA. Sallustio et al. in AJNR showed that using the ASPECTS score on CTA was a better predictor of outcome than using it on non-contrast CT, although also in AJNR Pfaff et al. demonstrated the utility of automated ASPECTS scoring (e-ASPECTS) as this also correlated with outcome (as well as with expert raters).

Tumour – The spectrum of leptomeningeal malignancy and its mimics is covered in a handy pictorial review in Neurographics by Salehi et al., including the multitude of leptomeningeal neoplasms as well as infectious and inflammatory causes. Mimics are also the subject of an article by Starr and Cha in Clinical Radiology, which highlights five key features to alert the radiologist that an apparent meningioma may not be what it seems – significantly high or low T2 hyperintensity, osseous destruction, leptomeningeal extension and lack of a dural tail. Finally, in JNS Starke et al. examine the dreaded pineal cyst, examining key features from their cohort that are associated with hydrocephalus and malignant transformation.

DegenerativeJennings et al. in JAMA Neurology showed the predictive value of dopaminergic imaging in Parkinson’s disease, showing that a combination of hyposmia and positive DAT-SPECT predicts a conversion to PD within four years; this could also be used as a quantitative biomarker to measure disease progression over time. It is worth also checking out the accompanying editorial (by Postuma) which places the findings in context.

Cerebral amyloid angiopathy is a common diagnosis but still presents a diagnostic dilemma and our pathophysiological understanding of the condition remains incomplete. Two articles published this month aim to help tackle this and are complementary in their aims. Firstly, a comprehensive radiological review in Neurographics, by Koren et al., which covers the imaging features and Boston diagnostic criteria as well as the rarer inflammatory subtype. Secondly, a broader, more clinically orientated overview in JNNP by Banerjee et al. examines the current state of knowledge and future directions for diagnosis and treatment.

SpineKralik et al. studied the utility of 3D SPACE imaging for the diagnosis of spinal dural arteriovenous fistula; as expected, abnormal flow voids associated with dAVFs were better seen on 3D imaging, however the authors stress the importance of using this in tandem with 2D T2 imaging for assessing cord signal change.

Miscellaneous – I never know which section PRES belongs in, and it seems I’m in good company as a practical review of the condition outlines in JNNP this month. Gao et al. present a review of the different theories of aetiology for this heterogeneous disorder, and most importantly for the radiologist stress that the diagnosis of PRES is far from the endpoint of investigation and should prompt a search for underlying causes.

With the controversy surrounding the significance of gadolinium deposition in the brain still very much alive, a review of pathology of the dentate nucleus seems timely, and Bond et al. provide a thorough summary of the functional anatomy and conditions affecting this area.

And finally, public service announcement of the month goes to Sriram et al. in JNS, who presented a case of penetrating spinal injury by a swordfish – a key differential to consider in the fisherman presenting with hemiparesis.

That’s all for this month, do let us know what you’ve found useful this month! Coming up over the next couple of weeks we have a summary of the recent UKNG annual meeting, and we’ll have highlights from the BSNR Annual Meeting towards the end of September – do follow us on @BSNRTrainees for updates.